I am far from being an HRT veteran. I’ve been using supplemental estradiol and progesterone to help treat my tumultuous perimenopausal symptoms for 20 months now. As most women who eventually decide to try HRT will tell you, it can take a while to get your optimal dosing and delivery routes mastered. At my age, I probably have a minimum of five years before I cross into official menopause.
Dosing refers to the amount, or prescription strength level, of estradiol or progesterone you are taking. For example, the typical dose of an ibuprofen pill is 200 mg. Similarly, estradiol comes in various standard dosages. Delivery route pertains to the manner in which you take your HRT. Generally, there are two mainstream routes – transdermal (through the skin) through a patch, cream or gel – and oral by taking pills. A less common route is beneath the skin through hormonal pellets, but you won’t find much information about that here.
Being on HRT for as long as I have, some might think I would have reached the height of results I could obtain. But I was wrong. While I was feeling much better – I’m talking leaps and bounds from the pits of my state in late 2020 – I was still experiencing periodic night sweats and rare episodes of what I call sub-threshold “alertness.” By that I mean that the rhythm of my day, usually night, could be thrown off kilter by anything that disrupted the predictability I now try to maintain in my daily regimen. An apt example would be the noise of a train outside rendering me hyper-alert even though I was just about to nod off into dreamland.
I knew that this was not entirely unusual. Women in perimenopause and menopause forums and communities online shared similar tales. Being more easily triggered by the mundane and having breakthrough sweats are associated with something being a bit off base hormonally. I was already at a relatively upper-limit-dose of estradiol, but I decided to proceed with my dilemma and visited my doctor anyway.
To make a long story short, it was decided that I could do a test run of changing my dosages and delivery routes. Though transdermal estradiol tends to be the go-to formula by most prescribers, this default choice may not take into account the differences in women and how we metabolize or process the supplemental hormones. In fact, many women complain that they don’t absorb estradiol well through the skin, especially with patches, or that they can feel the patch “run out” of hormones before it’s time to change it. Plus, estradiol patches are ridiculously expensive, even with insurance. The compounding cost over months and years, if totaled, can be astonishing.
So I am now taking oral estradiol for a spin. The results and differences so far are subtle, in that they feel completely natural and unforced. But the night sweats that were breaking through seem to have mostly ceased. (The treatment goal is not always complete remediation, but rather a statistical improvement. Yet that hasn’t stopped me from pursuing my personal hormonal Eureka.) Not only am I waking up dry, my mentality feels that much more dialed in. I am finding myself doing more of what I used to, somehow not overthinking to the extent I’m inclined to as a Type A person, and feeling less internal frustration with the theatrics and drama of having teenagers and a lot of real life stuff going on in the background.
These oral estradiol pills are where it’s at! At least for me right now.
The caveat and disclaimer here is that every woman is different, and the decision on the dosing and delivery of your hormonal therapy will need to be made in consultation with your doctor. Generally, oral estradiol is avoided for women considered at-risk, including being obese, diabetic, having a history of blood clots, smokers and others. Fortunately, I don’t have any of the risk factors that typically curtail doctors from prescribing oral estradiol in pill form.
Did I mention that it’s also much, much less expensive? Your mileage on cost may vary depending on your insurer or your budget, but I feel like it’s highway robbery for there to be such a premium on patches, when pills are exponentially cheaper and kinder to my wallet.
If you’re on estradiol patches and still not feeling quite right, my first recommendation would be to revisit the dose. Are you taking enough, or is your doctor playing it too safe and conservative? That is a common problem. Sometimes you may be able to convince your doctor to prescribe a higher dose, and other times you may have to seek out a provider who is more interested in helping you feel better than in doing HRT the lazy way – prescribing the same baseline dose to each woman.
If you increase your patch dosing and still are not satisfied, I think oral estradiol pills are a rationale proposal. I take mine in the morning each day, and I do not sense any diminishment in my day that could signal a hormonal slump. I feel level, even and balanced.
I will also add that I do a lot of other stuff aside from my estradiol pills, but I am not going to promote my personal lifestyle and prescription plan because every woman is different. I will say that the only thing I’ve changed recently is the addition of estradiol pills, and it feels absolutely wonderful.
When a woman is hit like a deer in headlights by perimenopausal or menopausal symptoms, she often is at her most vulnerable. With almost no warning or often without any foreboding sharing of information from elder women or healthcare providers, women find themselves sweaty and sleepless, anxious and depressed, dried out and all cried out – with virtually no answers or informed, trusted sources to help them.
Women in this position, at least for the few among us who find the strength to advocate for themselves and seek help, are willing to try almost anything. This often means a succession of visits to conventional medicine practitioners – a tour with stops to the internal medicine doctor, an OB/GYN, maybe second opinions of the former . . . and then this is where most women stop. They frequently give up because these doctors have no real solutions or real education on this critical juncture that all midlife women – basically half of the world’s population – will one day face. All too often, physicians tell these women to exercise more, dress in layers, reduce stress or even grin and bear it until it passes.
For the women who give up on mainstream doctors, they may turn to over-the-counter offerings, like various supplements, teas and other untested and unregulated concoctions, seeking relief from evening primrose oil, “menopause vitamins,” black cohosh and other oils, tinctures, herbs and pills.
Still finding little to no relief, said women then may turn to what may be her final frontier: functional medicine doctors and naturopaths.
Sadly, these practitioners often take advantage of perimenopausal and menopausal women by offering hyperbolic hopes, grandiose promises and incredible cures, usually under the umbrella of “natural,” “customized” or “personalized” care. And it doesn’t come cheap, with repeated rounds of testing, reports, office visits and so much more.
So, are naturopaths and functional medicine doctors the equivalent of healthcare quacks? Are they selling snake oil and preying on legions of vulnerable, desperate midlife women?
What are their credentials?
Naturopathic doctors are not necessarily trained or credentialed. Going into the pool of naturopathic medicine providers is like jumping into a hurricane; one may need to survive the harsh, whipping winds before reaching the more tranquil eye of the storm. There is no universal standard for licensing naturopathic practitioners. Some states require that they attend a four-year program, study basic sciences similar to those taught in medical school and pass a state licensing exam. But others have no training at all, being unskilled, unlicensed and with no education whatsoever.
Functional medicine doctors, on the other hand, have usually completed medical school and then earned additional credentials from functional or alternative medicine organizations, such as The Institute for Functional Medicine.
How do they approach perimenopause or menopause?
If menopause and perimenopause communities on Facebook or Reddit are any indication, functional medicine doctors and naturopaths have an interesting approach to managing midlife hormonal symptoms. Their approach often involves repeated, rigorous testing of hormone levels and other metrics, such as vitamin levels, thyroid counts and much more. Women have left untold numbers of remarks about paying $600-$1,000 for a single office visit. They are frequently “prescribed” expensive vitamins and supplements (some of which they later find could have been purchased online for much less), and they may get compounded hormone treatments (available through compounding pharmacies with which these naturopaths have established agreements or relationships). The compounded hormones are not the same as FDA-approved and regulated hormone replacement therapy (HRT) in the form of pharmaceutical grade gels, patches or sprays, and oral micronized progesterone (or Prometrium).
Naturopaths and functional medicine doctors are said to habitually link perimenopause symptoms with other alleged and unproven conditions, like thyroid issues, gut health and adrenal fatigue.
Science-Based Medicine writes: “The problem with ‘functional medicine’ is that at its core it is close to being as nonsensical as the more ‘obvious’ forms of quackery. It just hides it better, given the number of fancy-sounding laboratory tests.”
Is functional or naturopathic medicine evidence-based?
Conventional medicine is based on years of data and research, including clinical trials, empirical case studies, lab experiments and more. That’s how medicine arrives at standards of care for various conditions, and that’s also how prescribed medicines finally reach the level of consumer access, after efficacy and relative safety are vetted. This is not to say there aren’t problems with “Big Pharma” and that all too many physicians reach for the prescription pad and lowest common denominator too readily before actually listening to and looking at the woman before them in the examination room.
But is functional medicine or naturopathic medicine actually based on proven science? Well, both purport to be more “integrative” and “holistic” than their competition. This is described as “addressing the web-like interconnections of internal physiological factors,” and “seeking a dynamic balance among the internal and external factors in a patient’s body, mind and spirit.”
But this is tantamount to a “get out of jail free” card “for basically anything practitioners want to do,” according to Science-Based Medicine.
Insurance usually doesn’t cover naturopathic or functional medicine.
Going to a naturopath or functional medicine doctor is expensive – and generally not covered by health insurance. Most practitioners don’t (or don’t have the authority to) order conventional blood testing, so they use other means, like saliva testing, in an attempt to build out the spider web of imagined conditions their “patients” are suffering from. Plus, lab tests are not necessary to diagnose perimenopause.
“The reason insurance doesn’t cover most of these tests and that conventional physicians won’t order them is because they are unhelpful, useless and / or not based in science and evidence.”
Some of the tests often recommended or ordered include those for heavy metals, micronutrients, methylation, inflammation, gut permeability, adrenal stress and metabolism. These tests are sometimes followed by the caveat that they are not intended to diagnose or treat a disease or to substitute for a physician’s expertise.
Why don’t they just prescribe regular hormone replacement therapy?
Many women are still afraid to take standard HRT, largely based on the continued reputational damage done from the now-misguided 2002 WHI study, which caused millions of women to abandon hormonal treatment almost overnight. Oncologists like Avrum Bluming are now going ultra-public about the safety and benefits of HRT for the symptoms of perimenopause and menopause, including longer-term brain, heart and bone health, as are many gynecologists, women’s health specialists and even psychiatrists. In fact, HRT is now known as the “gold standard” for addressing perimenopause and menopause difficulties, many of which can be life-altering and debilitating.
But naturopaths and functional medicine doctors continue to corral mistruths about HRT’s safety and effectiveness, preying on women’s fears and desire to be “as natural as possible.” Dr. Jen Gunter blows up the confusion they add about “body identical” vs. “bioidentical” hormones in “Stop Using ‘Body Identical’ and ‘Bioidentical’ to Refer to Menopausal Hormone Therapy” in this piece.
One such practice in Metro Atlanta proclaims: “We offer complete counseling and diagnostic testing to help you determine which treatments are right for you. We always prefer to treat patients with the most natural, least invasive therapy possible. Dietary supplements such as Estrovera are effective at relieving the symptoms of menopause. Other therapies such as acupuncture, biofeedback and dietary changes can also have a profound impact on patients’ symptoms.”
This same practice requires a log-in to view the prices of the dozens of supplements they “prescribe.” But a quick online search of Estrovera reveals it costs about $123.00 for 90 pills – about the same or more than what a typical HRT prescription of bioidentical estradiol and progesterone cost without insurance. This product does seem to have mostly positive reviews, but many of the reviews are tainted by women’s expressed fears of going on HRT, trying to stay away from HRT as long as possible, or seeking relief of hot flashes only (when there are 100+ known symptoms of perimenopause that HRT mostly can address, including vasomotor symptoms).
So is a naturopath or functional medicine doctor right for you?
Only you can decide if seeing a naturopath or functional medicine doctor is right for you. In this case, as with all things that are potentially expensive in both time, energy, emotional labor and monetary cost, buyer beware.
Given the increasing amount of evidence about the tried-and-true solutions for perimenopausal symptoms, those with the greatest amount of efficacy remain FDA-approved HRT and low-dose antidepressants (for those who can’t or won’t use HRT, or for those who still have breakthrough anxiety, depression or insomnia).
Supplements, vitamins, exercise and nutrition have their place in the total continuum of well-being, whether you’re perimenopausal or not. These can be adjuncts to HRT, or in the case of exercise and nutrition as the foundation of health, serve as building blocks.
But there is little defensible grounds for paying hundreds or thousands of dollars on minimally proven – or even outright disproven – homeopathic “prescriptions” to treat menopause and perimenopause.
I recently had the privilege of being featured on Menopause Coach Kitty Anderson’s YouTube Channel, Create a Menopause Recovery in the video titled “Keisha Is a Black Woman Using HRT in the United States: Perimenopause Was Traumatic Without HRT!”
I responded to Kitty’s call for women of color to come forward and share their experiences of recovery from perimenopausal or menopausal symptoms, especially those who are using hormone replacement therapy (HRT). I actually encountered Kitty Anderson before; I enlisted her help to coach me through some continued challenges I was facing after I had started HRT months before. I even featured her on The Real Peri Meno blog in the post “Kitty Anderson: Menopause As a Social Justice Issue,”profiling her own journey as a menopausal woman who uses HRT herself and her experiences in becoming an expert on the topic.
My journey, from the process of realizing I was perimenopausal and not suffering from some other malady, and the maze I went through in navigating the medical system, is here on my blog on the post titled “Shocked By Perimenopause? I Was, Too.”
I wish more Black women (and women in general) would go public about their perimenopausal woes and the solutions that are working for them. While I am using HRT, I don’t expect ALL women to do so. But I do explore the reasons why Black women seem less likely to pursue HRT in “Why It Seems Like Black Women Don’t Use HRT.” Using HRT is a highly personal decision, just like choosing to use any prescription medication is.
Please watch / listen to the interview in depth. Here are a few points I considered after the fact that I want to state for the record:
Choose the medical practitioner, healthcare professional or physician who works for and with you! Regardless of color, too. That healthcare advocate who opts to partner with you in your care may not look like you, sound like you or any in way be like you, but they may be exactly what you need at that moment – and as a permanent ally in your long-term care. The best doctors in this journey for me have been an older (60+) white woman and a younger white man. It was a Black gynecologist who really let me down, along with a slew of others.
Be prepared to pivot. No day in perimenopause is guaranteed to be the same. Your symptoms may be well controlled and absent one day, and then they might pipe up the next. That may not necessarily mean that you need to reinvent the wheel, but it does mean that a versatile mindset is more important now than perhaps it has ever been. As symptoms change during perimenopause, and as hormones choose to cause a commotion every now and again (even while on HRT), realize that dosages may change, you may need to add in new medications and you may need to drop things that no longer work for you.
If you speak out about perimenopause, be prepared for . . . silence. When I went public about my perimenopause experience, I knew it was going to require being vulnerable. I didn’t know how people would react or what they would say. So far, in terms of my personal sphere, the response has largely been one of silence. No one I know personally is really asking any questions or sharing any of their experiences, but I know they are reading the material here, taking notes and considering options. I started this blog to help others, even as I continue to help myself in the background.
The Real Peri Meno is devoted to all things perimenopause - the science, treatments, care, understanding, personal experiences, relationships, culture and more. The brain child of Keisha D. Edwards, The Real Peri Meno developed out of her own shock-and-awe experience with perimenopause and navigating the disjointed U.S. medical system in search of answers, support and relief.
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